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APPLICATION FOR PERMIT SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZEL TON AVE., STOCKTON, CA Telephone (209) 466-6781 PERMIT EXPIRES 1 YEAR FROM DATE ISSUED (Complete in Triplicate) Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described.This application is made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin Local Health District. j� Job Address 1ef/O 1 � city �ize ✓ �' PM Owner's Name 'v� ' " 'F LLO gess ! 1 77500 S")WS00phone Z3 -7 21 Contractor Address License No. Phone TYPE OF WELL/PUMP: NEW WELL ❑ WELL REPLACEMENT ❑ DESTRUCTION ❑ PUMP INSTALLATION ❑ SYSTEM REPAIR ❑ OTHER ❑ DISTANCE TO NEAREST: SEPTIC TANK — SEWER LINES DISPOSAL FLD. PROP. LINE FOUNDATION AGRICULTURE WELL OTHER WELL PITS/SUMPS INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION SPECIFICATIONS ❑ Industrial ❑ Open Bottom ❑ Manteca Dia. of Well Excavation Dia. of Well Casing ❑ Domestic/Private ❑ Gravel Pack ❑ Tracy Type of Casing Specifications �1 ❑ Public ❑ Other ❑ Delta Depth of Grout Seal Type of Grout ❑ Irrigation ---Approx. Depth ❑ Eastern Surface Seal Installed by Repair Work Done ❑ Type of Pump H.P. State Work Done Well Destruction ❑ Well Diameter Sealing Material (top 501 Depth Filler Material (Below 501 TYPE OF SEPTIC WORK: NEW INSTALLATION 71 REPAIR/ADDITION ❑ DESTRUCTION ❑ (No septic system permitted if public sewer is available within 200 feet.) Installation will serve: Residence X Commercial_ Other / Number of living units:/ Number of bedrooms a & Character of soil to a depth of 3 feet: Water table depth SEPTIC TANK 1z9. Type/Mfg L Capacity No. Compartments 2– PKG. TREATMENT PL ❑ / Method of Disposal Distance to nearest: Well MQ Foundation Property T Property Line LEACHING LINE No. & Length of lines 3 k y/1 Total length/sizeZy FILTER BED ❑ Distance to nea--- Well/1d_ Foundation fU��/ Property Line f SEEPAGE PITS ElDepth° � .. Size lumber SUMPS X Distance to nearest: WellItf?9/ Foundation�((�L Property Line DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state laws, and rules and regulations of the San Joaquin Local Health District. Home owner or licensed agent's signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become subject to workman'scompensation laws of California."Contractor's hiring or sub-contracting signature certifies the following:"I certify that in the performance of the work for which this permit is issued,I shall employ persons subject to workman's compensa- tion laws of California." The applicant must call for all requiredins c' ns. Complete drawing on reverse side. Signed X IAC CA 0 Title: �7it/�/tr®_�/ Date: R DEPARTMEN USE ONLY y{� Application Accepted by lt� Date v Area Pit or Grout Inspection by AdA,vDate Final Inspection by Date Additional Comments: ❑ Stk 466-6781 ❑Lodi 369-3621 enteca 823-7104 ❑Tracy Applicant- Return all copies to: Environmental ealth Permit/Services 1601 E. Hazelton Ave., P.O. Box 2009, Stk., CA 95201 FEE AMOUNT DUE AMOUNT REMITTED RECEIVED BY DATE PERMIT NO. INFO — EH 4-26 Q��-24(REV.1/85) Q . �<� 7� t /y 1Z